Yaw Amofa Peprah

Background: Remote patient monitoring (RPM) includes home blood pressure (BP) measurement with readings sent directly to the electronic health record (EHR). We hypothesize that RPM facilitates quicker, more frequent, more appropriate antihypertensive medication changes. Methods: Patients with hypertension in 6 primary care clinics were prescribed RPM between November 2020 and August 2021 (N = 288) and matched to 4 control patients (N = 1152). Office and RPM BP readings and medication data over 18 months were extracted from the EHR. RPM patients were classified as baseline-controlled (office and RPM <130/<80 mmHg), sustained (office and RPM ≥130 and/or ≥80), white-coat (office ≥130 and/or ≥80, RPM <130/<80), or masked hypertension (office <130/<80, RPM ≥130 and/or ≥80). Results: RPM patients had earlier first antihypertensive medication changes, with half of RPM patients having ≥1 change by 228 days versus 530 days for controls. RPM patients had more total medication changes, with 25% of RPM patients having ≥4 (median 1; 25th-75th percentiles 0-4) changes versus ≥2 (median 1; 0-2) changes in controls. Compared to baseline sustained hypertension RPM users, white-coat hypertension users were less likely to have ≥1 medication increase (24% [N = 11] versus 53% [N = 74], P = .001) within 12 months. Compared to baseline-controlled RPM users, masked hypertension users were less likely to have ≥1 medication decrease (0% [N = 0] versus 44% [N = 8]; P = .003) within 12 months. Conclusions: Even without additional staff dedicated to medication adjustment, RPM facilitated quicker medication changes, more total changes, and differential prescribing decisions for white-coat and masked hypertension patients supporting RPM use in primary care. Clinical trial registration number: ClinicalTrials.gov identifier: NCT05562921.

BACKGROUND: Automated patient messages based on home blood pressure (BP) may help overcome clinician and patient inertia in hypertension treatment. METHODS: We designed and piloted an automated messaging system based on remote patient monitoring (RPM) results delivered through patients’ electronic health record portal. Messages included reminders to monitor, what to do if BP is above or below goal, and positive feedback when goal BP is achieved; these were triggered via a deterministic algorithm based on reported home BPs. Seven clinicians agreed to participate in this pilot study. Patients with the most recent two office BPs ≥140/90 mmHg were eligible. Outcomes assessed after 9 months included change in home SBP, net change in antihypertensive medication, and number of automated messages. Subgroup analysis was conducted by baseline home BP. RESULTS: Of 285 eligible patients, 70 (25%) enrolled. Baseline mean (SD) office systolic/diastolic BP was 148(18)/81(12) mmHg. By 9 months, participants had received a mean (range) of 13 (5–44) messages and viewed 85%. Among 64 patients completing the 9-month study visit, the baseline home BP was 142(17)/84(15) mmHg, 9-month change in home SBP was −9.4 mmHg (95% CI: −1.3, −14.7). Among 13 patients with controlled baseline home BP (<130/80 mmHg), SBP change was +2.7 mmHg (−4.8, +12.3). Among 51 patients with uncontrolled baseline home BP, SBP change was −12.5 mmHg (−5.2, −16.8); 51% had antihypertensive pharmacotherapy increased. CONCLUSIONS: Delivering automated feedback based on RPM BP results through a commercial electronic health record was feasible. Participants with sustained hypertension had large BP declines.

This pragmatic matched cohort study using EHR data extended the follow up to 18 months for BP outcomes comparing individuals prescribed remote patient monitoring (n = 288) and temporally-matched controls (n = 1152) from six primary care practices. After 18 months, the RPM-prescribed cohort had greater BP control < 140/90 mm Hg (RPM cohort: 71.5%, control cohort: 51.9%, p < 0.001) and lower systolic BP (131.6 versus 136.0 mm Hg, p = 0.004) using office and home measurements. BP control at 18 months assessed by office measurements only was also higher in the RPM group (62.2% versus 51.9%, p = 0.004).

Effective strategies are needed to curtail overuse that may lead to harm. To evaluate the effects of clinician decision support redirecting attention to harms and engaging social and reputational concerns on overuse in older primary care patients. 18-month, single-blind, pragmatic, cluster randomized trial, constrained randomization. (ClinicalTrials.gov: NCT04289753). 60 primary care internal medicine, family medicine and geriatrics practices within a health system from 1 September 2020 to 28 February 2022. 371 primary care clinicians and their older adult patients from participating practices. Behavioral science-informed, point-of-care, clinical decision support tools plus brief case-based education addressing the 3 primary clinical outcomes (187 clinicians from 30 clinics) were compared with brief case-based education alone (187 clinicians from 30 clinics). Decision support was designed to increase salience of potential harms, convey social norms, and promote accountability. Prostate-specific antigen (PSA) testing in men aged 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women aged 65 years and older, and overtreatment of diabetes with hypoglycemic agents in patients aged 75 years and older and hemoglobin A_1c (HbA_1c) less than 7%. At randomization, mean clinic annual PSA testing, unspecified urine testing, and diabetes overtreatment rates were 24.9, 23.9, and 16.8 per 100 patients, respectively. After 18 months of intervention, the intervention group had lower adjusted difference-in-differences in annual rates of PSA testing (-8.7 [95% CI, -10.2 to -7.1]), unspecified urine testing (-5.5 [CI, -7.0 to -3.6]), and diabetes overtreatment (-1.4 [CI, -2.9 to -0.03]) compared with education only. Safety measures did not show increased emergency care related to urinary tract infections or hyperglycemia. An HbA_1c greater than 9.0% was more common with the intervention among previously overtreated diabetes patients (adjusted difference-in-differences, 0.47 per 100 patients [95% CI, 0.04 to 1.20]). A single health system limits generalizability; electronic health data limit ability to differentiate between overtesting and underdocumentation. Decision support designed to increase clinicians' attention to possible harms, social norms, and reputational concerns reduced unspecified testing compared with offering traditional case-based education alone. Small decreases in diabetes overtreatment may also result in higher rates of uncontrolled diabetes. National Institute on Aging.

Remote patient monitoring (RPM) for hypertension enables automatic transmission of blood pressure (BP) and pulse into the electronic health record (EHR), but its effectiveness in primary care is unknown. This pragmatic matched cohort study using EHR data compared BP outcomes between individuals prescribed RPM and temporally-matched controls from six primary care practices. We retrospectively created a cohort of 288 Medicare-enrolled patients prescribed BP RPM (cases) and 1152 propensity score-matched controls (1:4). Matching was based on age, sex, systolic blood pressure (SBP), marital status, and other characteristics. Outcomes at 3, 6, 9 and 12 months were: controlling high BP (most recent BP < 140/90 mm Hg), antihypertensive medication intensification, and most recent SBP assessed using: all measurements, and office measurements only. At baseline, RPM-prescribed patients and controls had similar ages and systolic BP. BP control diverged at 3 months (RPM: 72.2%, control: 51%,p < 0.001). This difference persisted but decreased over follow-up. After 12 months, the RPM-prescribed cohort had greater BP control (RPM: 71.5%, control: 58.1%,p < 0.001) and lower SBP (132.3 versus 136.5 mm Hg,p = 0.003) using all measurements, but they did not differ using only office measurements (12 month BP control: 60.8% versus 58.1%,p = 0.44; SBP: 135.9 versus 136.5 mm Hg,p = 0.91). At 12 months, the most recent BP measurements were more current for RPM-prescribed patients (median [IQR] 8 [0–109] versus 134 [56–239] days). Net increases in antihypertensive medications by 12 months were similar. Implementation of RPM in primary care could inform hypertension management strategies and increase hypertension control. Registration: ClinicalTrials.gov identifier: NCT05562921.

The accuracy of Omron 10 Series BP7450 (HEM-7342T-Z), Omron Platinum BP5450 (HEM-7343T-Z), Walmart Equate Premium 8000 Series UA-8000WM, Walgreens Premium 15+ WGNBPA-960BT, and CVS Series 800 BP3MW1-4YCVS were assessed in an adult general population compared to a mercury sphygmomanometer standard according to the ISO 81060-2:2018/AMD 1:2020 validation procedure. Omron selected the monitors and included three non-Omron monitors because they were from large retail vendors in the United States and these monitors did not have accessible results from validation testing. The BP7450, N = 85, passed both criteria for the standard. Mean (SD) differences in paired SBP and DBP determinations between the test device and reference were 0.5 (7.7) and 2.5 (6.8) mm Hg. The BP5450, N = 86, passed both criteria. Mean (SD) differences in paired SBP and DBP determinations were 1.9 (7.0) and 3.6 (6.4) mm Hg. The UA-8000WM, N = 85, did not meet the first criterion for the standard. Mean (SD) differences in paired SBP and DBP determinations were 2.5 (8.0) and 5.1 (6.4) mm Hg. The WGNBPA-240BT, N = 85, did not meet the first criterion for the standard. Mean (SD) differences in paired SBP and DBP determinations were 7.9 (8.5) and 5.5 (6.7) mm Hg. The BP3MW1-4YCVS, N = 85, did not meet the first criterion for the standard. Mean (SD) differences in paired SBP and DBP determinations were 5.8 (8.7) and 3.1 (5.6) mm Hg. These findings emphasize the importance of verifying the validation status of home blood pressure monitors before use by consumers.